Basic life support in a child; Advance life support in a child; Neonatal resuscitation; Umbilical catheterization

1. Department Family Medicine
Dora Nginza Hospital
Kemi Dele-Ijagbulu, M.B.Ch.B
Paediatrics Resuscitation

2. O U T L I N E
1. PAEDIATRIC RESUSCITATION
1. Basic life support in a child
2. Advance life support in a child
3. Neonatal resuscitation
4. Umbilical catheterization

3. PAEDIATRIC RESUSCITATION
A. BASIC LIFE SUPPORT
B. ADVANCE LIFE SUPPORT
C. NEONATAL RESUSCITATION
D. UMBILICAL VESSEL CATHERIRIZATION

4. CHALLENGES IN PAEDIATRIC
RESUSCITATION?
• Children are NOT just little adults!
• Different anatomy, different physiology and different pathology.
• Varying equipment shapes and sizes with varying ages.
• Challenging vascular access
DEFINITIONS
• A newborn is a child just after birth.
• A neonate is a child in the first 28 days of life.
• An infant is a child under 1 year.
• A child is between 1 year and puberty.

5. PAEDIATRIC CHAIN OF SURVIVAL
PREVENTION CPR EMS ALS
INTEGRATED
POST–CARDIAC
ARREST CARE

6. BASIC LIFE SUPPORT

8. BASIC LIFE SUPPORT
• HAZARD: ensure safety of rescuer and victim
• HELLO: check for response (call name. Are you okay?) Responsive
unresponsive
• HELP: if unresponsive, not breathing or only gasping, get
AED/defibrillator
• Assess the need for CPR (BOX 1) if the victim is unresponsive and is not
breathing (or only gasping), send someone to activate the emergency
response system. If responsive with regular breathing, the victim does not
need CPR, put in recovery position

9. CIRCULATION
• Check pulse within 10secs (brachial in an infant and carotid or femoral in a
child).
• Pulse: 1 rescue breath every 3 seconds)
• No pulse: Start Chest Compressions

10. COMPRESSIONS
For infants:
• Compress the sternum with 2 fingers placed just below the intermammary
line.
• The 2-thumb–encircling hands technique is recommended when CPR is
provided by 2 rescuers (encircle the infant's chest with both hands; spread
your fingers around the thorax, and place your thumbs together over the
lower third of the sternum and forcefully compress the sternum with your
thumb)
For older child:
• compress the lower half of the sternum with the heel of 1 or 2 hands.

11. VENTILATIONS
• Ventilations (box 4): after 30 compressions (15 compressions if 2 rescuers),
open the airway with a head tilt–chin lift and give 2 breaths. Bag-mask
ventilation can be provided effectively during 2-person CPR
• AIRWAY open the airway using a head tilt–chin lift manoeuvre for both injured
and non-injured victims. If there is evidence of trauma that suggests spinal
injury, use a jaw thrust without head tilt to open the airway. Because maintaining
a patent airway and providing adequate ventilation is important in paediatric
CPR, use a head tilt–chin lift manoeuvre if the jaw thrust does not open the
airway. In spinal injury, plane of face parallel to spine board
• BREATHING: give 2 effective breaths after 15 compressions for 2 rescuers/ 30
compressions lone rescuer. (Effective breaths = the chest rises)

12. BASIC LIFE SUPPORT CONT.
ANALYSE RHYTHM: AED IN CHILDREN
• Shockable: 1 shock continue CPR
• Non-Shockable: continue CPR until patient becomes responsive or ALS
providers take over
Age > 8 years: use adult AED
•Age 1-8 years: use paediatric pads/settings if available (otherwise use adult mode)
•Age < 1 year: use only if manufacturer instructions indicate it is safe
REASSES after 2min for pulses
Present: post-resuscitation care
Absent: continue CPR

13. PAEDIATRIC ADVANCED LIFE SUPPORT

14. AIRWAY
By now you should’ve established whether your patient is able to maintain his/her own
airway
Decide on the appropriate airway adjunct to provide adequate ventilation.
Oropharyngeal and nasopharyngeal airways
• Oropharyngeal and nasopharyngeal airways help maintain an open airway by displacing
the tongue or soft palate from the pharyngeal air passages.
• Oropharyngeal airways are used in unresponsive victims who do not have a gag reflex.
• Nasopharyngeal airways can be used in children who do have a gag reflex.
• Size determination
• Oropharyngeal airways: age/2 + 12
• Nasopharyngeal airways age/2 + 15

15. AIRWAY – CONT.
• Oxygen: monitor systemic oxygen saturation. Titrate oxygen administration to maintain
the oxyhemoglobin saturation ≥94%.
• Pulse oximetry: monitor oxyhemoglobin saturation continuously with a pulse oximeter.
Pulse oximetry may, however, also be unreliable in patients with poor peripheral
perfusion, carbon monoxide poisoning, or methemoglobinemia.
• Bag-mask ventilation: selecting a correct mask size, maintaining an open airway,
providing a tight seal between mask and face, providing ventilation, and assessing
effectiveness of ventilation
• Ventilation with an endotracheal tube
• Endotracheal tube size
• ETT SIZE DETERMINATION (USE UNCUFFED TUBES)
• < 1yr: 3-3.5mm
• >1yr: age/4 + 4

16. ANATOMICAL AIRWAY DIFFERENCES
ANATOMICAL AIRWAY DIFFERENCES
• Large head, short neck – airway narrowing
• Small jaw, loose teeth, big tongue – difficult intubation
• Horse shoe larynx – straight blade laryngoscope
• Cricoid cartilage with surrounding loose connective tissue – susceptible
to oedema

17. BREATHING
Breathing – can patient maintain spontaneous ventilation or is measure
necessary to provide adequate oxygen.
• Decide on the appropriate airway adjunct to provide adequate ventilation.
Anatomical breathing differences
• Nose breathers and smaller airways – easily obstructed
• Horizontal ribs – reduced expansion
• Diaphragmatic breathing – fatigue causing respiratory failure

18. CIRCULATION
• Observe for any signs of active haemorrhage. Assess for cardiac dysthymias.
Vascular access:
• Vascular access – peripheral ivvenous access is essential for administering
medications and drawing blood samples.
Intraosseous (IO) access:
• IO access is a rapid, safe, effective, and acceptable route for vascular access in
children, and it is useful as the initial vascular access in cases of cardiac arrest.
All intravenous medications can be administered intraosseously, including
epinephrine, adenosine, fluids, and blood products
Circulation differences
• Blood volume (70-80ml/kg)
• Small blood volume loss is more significant than in adults

19. DRUGS/DEFIBRILLATE
• DRUGS/DEFIBRILLATE IF INDICATED
• ADENOSINE AMIODARONE CALCIUM EPINEPHRINE GLUCOSE MAGNESIUM
PROCAINAMIDE SODIUM BICARBONATE VASOPRESSIN
• DRUG DOSAGES AND JOULES FOR SHOCKING ARE DIFFERENT
• BY NOW EITHER A SUCCESFUL RESUS HAS BEEN COMPLETED OR NOT

20. NEONATAL RESUSCITATION

22. UMBILICAL CATHERIZATION

23. UMBILICAL CATHERIZATION
INDICATIONS
Vein:
• Emergency IV access for the administration of fluid, drugs, or hypertonic
glucose
• Monitoring CVP
• Venous blood sampling
• Exchange transfusions
• Central venous access in patients needing long term parenteral nutrition
Artery
• Arterial blood sampling /Arterial blood pressure monitoring / Angiography
• Administration of fluids and drugs

24. UMBILICAL CATHERIZATION – CONT.
Contraindications
• Peritonitis
• Necrotizing enterocolitis
• Omphalitis / omphalocele / gastroschisis
• Peritonitis
• UAC: evidence of local vascular compromise in lower limbs or buttocks
• UVC: portal venous hypertension

25. UMBILICAL CATHERIZATION – CONT.

26. TECHNIQUE
1. Place the infant beneath a radiant warmer and restrain the extremities.
2. Prepare the abdomen and umbilicus with antiseptic solution (surgical prep).
3. Drape the umbilical area in a sterile manner. Expose the infant’s head for
observation.
4. To anchor the line after placement, place a constricting loop of umbilical tape at
the base of the cord. Using a scalpel blade, trim the umbilical cord to 1 to 2 cm
above the skin surface.
5. Identify the umbilical vessels. The umbilical vein is a single, thin-walled, large-
diameter lumen, usually located at 12 o’clock. The arteries are paired and have
thicker walls with a small-diameter lumen.
6. Obtain an umbilical vascular catheter (5 fr). Flush the catheter with heparinized
saline (1 unit per ml) and attach it to a 3-way stopcock.

27. TECHNIQUE – CONT.
7. Measure and mark 5 cm from the tip of the catheter.
8. Close the ends of a pair of smooth forceps, then insert the end into the lumen
of the umbilical vein. Dilate the opening by allowing the ends of the forceps to
separate, then insert the catheter into the lumen of the umbilical vein and advance
it gently toward the liver for 4 to 5 cm or until blood return is noted.
9. If resistance to advancement of the catheter is encountered, the tip might be in
the portal vein or the ductus venosus. The catheter should be pulled back until
blood can be withdrawn smoothly.
10. Remove the catheter when resuscitation is complete and peripheral vascular
access has been obtained.

28. THANK YOU!